Last Week at Santa Rosa!

Reflections, Stories, and Things I've Learned

This is last week volunteering at the Santa Rosa Health Center and I am sad! I have had an amazing experience and will definitely miss spending time with all of the wonderful people I have gotten to know. As I think back and reflect on the last eight weeks, I am amazed when I think about how much I have learned. 

For example...

My Spanish vocabulary has grown immensely. I have become comfortable giving commands formally and informally to the patients as they come in and have learned a handful of new words and phrases, such as... 

Perímetro cefálico – Cephalic perimeter (head circumference)

Presión arterial – blood pressure

Bien pegado – “stand up straight”

Archivar – to file 

Odontología - dentistry

 Quítese la casaca, por favor - Please take off your jacket

Tome el asiento - Take the seat

Voy a tomar su presión - I'm going to take your blood pressure

Espere afuera - Wait outside

¿Para quién es la atención? - Who is the attention for?

Sácale de su ropa – Take off his/her clothes

...and so much more!

 I feel like my ability to converse naturally and quickly with the patients who come in has improved significantly. I am able to answer questions that the patients may have instead of just referring them to a more fluent Spanish speaker. 

In addition to improving my Spanish vocabulary and speaking ability, I also have developed and honed a variety of new skills that pertain to working in a health center. 

*I know how to weigh and measure patients when they are called to the triage area and recently I have learned how to take blood pressure as well. 

*I have also learned how to correctly weigh and measure the babies in the healthy child control area. Measuring the babies accurately is quite the chore as it is very difficult to get them to be perfectly straight and flat but I feel like I have definitely improved. 

*I also know how to do a psychomotor evaluation for babies of various ages. 

*On a handful of occasions, I have performed a curación del ombligo, or cleaning of the navel and umbilical cord, that is required for all the newborns who come into the clinic. (The very first time I had to clean the bellybutton of a baby, it was comical! That day, there was a mountain of babies who needed to be seen by the doctors and we were all incredibly busy. A mother brought in her newborn baby and I sent her to buy the sterilized gloves that were necessary for the doctor to clean the bellybutton. When the mother returned, I asked the doctor, who was busy with her head buried in the piles and piles of paperwork that must be completed for each patient, if she would clean the bellybutton. Without looking up from her work, she asked me "Do you know how to do it?" At that point I had only watched a few times while she cleaned a bellybutton and so I appropriately replied "No, I do not." She looked up from her work for just a moment, looked me in the eye, and sternly said "Learn."  She put her head back down and proceeded to fill out forms.  I found this comical because she never bothered to teach me how to do it; she only told me to "learn." Of course, I pulled on the gloves and used the tiny gauze squares with a squirt of alcohol to remove the crusties and goobers and clean out the navel. Since that day, I have cleaned several other bellybuttons, each time with more confidence that I know what I am doing.) 

*I have become acquainted with the somewhat confusing filing system and can pull a long list of files in no time at all. 

*I also can fill out new files and paperwork when new patients or newborn babies come into the clinic. 

I'm sure that this list does not even include all of the simple tasks that I have become accustomed to doing at the health center on a regular basis. Even though I have loved learning how to do these things and doing them, there are other lessons of deeper importance that I have learned during my time at the health center.

There are people who come to the health center seeking help despite incredibly difficult circumstances. While there is free (or nearly free) insurance for most patients, the simple task of arriving at the health center can be a great feat for some of the patients. There are some people who have to walk great distances up and down  incredibly steep hills on rugged dirt roads in the beating sun or in pouring rain. In order to get confirm an "appointment" with the doctor (although, I would never use the word appointment to describe what happens in the health center), it is necessary to arrive at the clinic very early in the morning. The first patients who receive attention often have waited outside the doors of the health center since 5am in the morning. The patients have to wait in a very long line in order to place their name on the list to receive medical attention. After placing their names on the list, they have to wait until they are called by the nurses in traige and then wait more for the doctors to call them back to the treatment rooms. They often wait for hours and hours in the waiting area, which consists of a few rows of benches lined up on a mound of dirt and gravel underneath a patchy tin roof in front of the health center. There are people waiting outside in the down pouring rain or in the dry heat of the sun from early in the morning until the center closes for the day.

This has made me realize how much I take for granted at home in the United States. When I need to go to the doctor, I call, make an appointment, and show up at that specific time. I have often complained as I've sat comfortably in the padded chairs in the quiet, air-conditioned waiting room if I've had to wait for even just a few minutes for the doctor or nurse to call my name. I can't imagine that I would ever go to the doctor if I had to arrive at 5am and then sit and wait for five hours or more, possibly in the pouring rain, just to be seen by a medic for a few minutes. The people here make a much bigger sacrifice in order to receive medical attention. They are much more patient and typically everyone waits courteously outside for their name to be called. 

In addition to this, it is very clear that the Santa Rosa district of Cusco is a very poor part of town. I have seen traditionally dressed women come in wearing the typical sandal-type shoes with extremely dirty feet. When they remove their sandals, mud and dirt often have formed an outline where the straps had been. Sometimes the people have a distinct body odor scent, as if they haven't bathed in several days. I have noticed some patients wearing the same clothes on multiple different days when they have come in. When I explored the Santa Rosa district with the obstetricians for a few days a while ago, we wandered up and down many, many streets of mud brick adobe homes. The streets were dirt and mud, bumpy and jagged with holes, bumps, and channels where the water would run. The dwellings were constructed entirely from the adobe bricks composed of mud and straw. Dogs, cats, chickens, and sheep lived right alongside these people around their humble homes. I'm sure some of them had electricity of some sort, but I would be very surprised if these people have televisions, computers, or internet in their homes. 

Something as simple as personal hygiene is definitely something I have taken for granted as well. It is so easy to be accustomed to having luxuries such as a warm shower and clean clothes on a regular basis that I forget to be thankful for even these simple things. In the United States, we are overwhelmed and bombarded with the desire to always buy new things, new clothes, and new toys to the point that we feel a sense of entitlement to these things. I don't believe it is a bad thing to buy new clothes or to take a shower everyday, but I do think that is it very important to maintain a humble attitude of appreciation for the luxurious lifestyles that we have been blessed with. I'm sure that there are many people around the world who live in much worse conditions that even those that I have seen during my time here. 

Despite seeing many sad situations, my time at the public health center has been filled with positive memories. There is one young mother who I have seen in the center multiple times. Her baby had been born shortly before I arrived. He was very small and very malnourished. I remember watching the young mom wipe tears from her eyes as the doctor lectured her about the state of her newborn baby during his first or second checkup. Just yesterday I saw the same mother bring her two-month-old baby into the clinic; he now is a chubby young little guy with thick legs and round cheeks. His weight and height were right where they needed to be for a baby of his age. 

It is so wonderful to reflect on such a positive outcome to this story. If the young mother (who is 15 years old, by the way... I checked her file) had not chosen to bring her baby boy in for his regular controls, she may have not known that he was severely malnourished. In the worse possible outcome, the baby could have died from malnutrition if he did not receive more attention. Fortunately, the mother had access to care and chose to put forth the effort to bring her child into the clinic once a week or sometimes even more frequently than that. 

I have been incredibly blessed to have had such a wonderful experience at the Santa Rosa Centro de Salud and am very sad that my time there has come to an end. Tomorrow, Thursday, the 13th of March, will be my last official day. Although it would be easy to go to the health center with a heavy heart tomorrow, sad that it will be the last few hours I will spend there, I would rather go with a positive spirit, thankful for the wonderful experiences I have had and the relationships I have formed with such amazing people. It will be hard to say goodbye, no doubt, but I can be joyful knowing that I have been able to make a difference at the health center I love so much.

The Latino Patient – The Clinical Encounter

GREET: Characterizing the Latino Patient

After covering relevant cultural values and the belief systems of the Latino population and addressing variations in the beliefs due to generational differences, The Latino Patient moves on to present a culturally competent care model for Latinos. It begins by offering the acronym “GREET” as a way to characterize Latino patients. By gathering relevant background information about each individual, healthcare providers can increase their understanding of the personal and cultural history of each patient. Expressing an interest in the patient’s personal background can also increase the amount of respect that is perceived by the patient. The GREET acronym is as follows:

G = Generation

R = Reason for Immigrating to the US

E = Extended or Nuclear Family

E = Ethnic Behavior

T = Time Living in the US

Generation

It is important to determine whether the patient is an immigrant or a second-, third-, or fourth-generation Latino. The degree of acculturation varies with each generation and each brings to the table its own set of unique characteristics. The later generations are much more similar to the mainstream culture than recent immigrants

Reason for Immigrating to the US

Knowing a patient’s individual reason for immigrating to the United States can give the healthcare provider insight into the social, political, and economic stressors that may affect the mental and physical health of the patient.

*This category does not apply to second-, third-, or fourth-generation Latinos.

Extended or Nuclear Family

By gathering information about the living circumstances of the patient, the healthcare provider can have an increased understanding of the social support network that the patient may or may not have. Typically, in the Latino culture extended or nuclear family members live in close proximity to each other. This can present problems for immigrants if they are unaccustomed to living far from family.

Ethnic Behavior

It is useful to gather information about the patient’s personal preferences in regard to food, music, holidays, and recreational activities. This is important because habits such as consumption of alcohol at parties or celebrations can have significant health implications.

Time Living in the US

As variation in acculturation is seen from generation to generation, similar variation is seen as the time spent living in the United States increases. Patients who have recently immigrated will cling more tightly to traditional Latino cultural values, while second-generation Latinos who have lived their entire lives in the US will be more similar to the mainstream culture.

The Clinical Encounter

There are a few important points to keep in mind during the initial part of the clinical encounter with a Latino patient. While the healthcare provider may be accustomed to interacting with a diverse clientele, it may be a new, and sometimes scary, experience for the Latino patient. Cultural and language barriers can be equally, if not more, intimidating for the patient, who is making an effort to seek medical attention in a health system that may be entirely different from the system in the country of origin. With this in mind, there are a number of crucially important factors that should be taken into consideration during the initial interaction with the patient.

Eye Contact

As a sign of respect, making eye contact with the patient is critical; however, it is important to be careful with gender differences. Maintaining eye contact for an extended period of time with a person of the opposite gender may be perceived as an attraction towards that individual.

Facial Expression

A simple smile and friendly facial expression can work wonders in setting the tone for the entire clinical encounter. The combination of a smile and eye contact can make the patient feel accepted and welcome in the office. A stern face can send the message that the health care provider is unhappy with the language or cultural barrier.

Gestures and Touch

Gestures such as standing up when the patient enters the room and gesturing towards a chair while greeting a patient can send a welcoming message. It also shows respect for the patient. A warm, firm handshake upon greeting the patient can also contribute to the feelings of respect perceived by the patient.

Voice Intonation

Healthcare providers will be best-received if they talk in a friendly voice that is neither too loud nor too quiet. A loud, abrupt voice may give the impression that the healthcare provider is ill-tempered, impolite, or upset with the patient. A quiet voice may imply a lack of personality.

Titles

The use of titles is very important in the eyes of Latinos and conveys respect for the patient. By using titles such as Señor (Mr.), Señora (Mrs.), and Señorita (Miss) before the last name of the patient, the healthcare provider can show respect for the patient and gain respect in his or her eyes.

The Latino Patient – Effective Communication

Delivering Health Messages Successfully

While conveying health messages to Latinos can be difficult at times, by taking the cultural values into account, a health professional can increase the effectiveness of the communication. In order to initiate change in a behavior of a Latino patient and to help maintain the change, it is important to consider four different factors: familism, friends, faith, and fatalism.

Familism

While the Latino culture is not individualistic, telling a patient to change a habit in order to improve personal health may not be a sufficient reason to invoke change. As the culture is more family oriented, implying that changing a habit may be beneficial for the family is much more likely to result in a change in the behavior.

For example, to encourage a smoker to quit smoking, one might say that changing the habit will allow the patient to…

• ×          Live a longer life and have the pleasure of knowing his or her grandchildren
• ×          Set a good example for children
• ×          Protect family members from suffering or harm caused by secondhand smoke
• ×          Save money for a family vacation

Friends

Similar to the idea of familism, Latinos highly value their social relationships and connections. The opinions and advice given by close friends are held in high regard and have strong influence over the actions of many Latinos. Again, encouraging a habit change in order to achieve a personal goal is not likely to produce a change. On the other hand, referencing issues related to friends and relationships may have a greater impact on the patient.

For example, to encourage an alcoholic to attend AA meetings, one might say that joining AA will allow the patient to…

• ×          Help friends who struggle with the same problem
• ×          Be accepted by friends
• ×          Influence and be influenced by others in the social group

Faith

Religious faith and faith in the health care provider are both very important. Many Latinos believe strongly in the power of God to heal and direct the outcome of all circumstances. When an illness is experienced, Latinos may visit shrines and offer prayers, candles, or other offerings to God or saints with hopes that they will cure the illness. Faith can also be placed in a trustworthy health care provider with whom the patient has had past experience and successful outcomes. This faith can help encourage a patient to begin or maintain a healthy lifestyle change.  As a health care provider, alluding to a patient’s faith in God can be beneficial in encouraging the change.

Fatalism

Fatalism is the concept that all events are predestined and that all humans are subject to an unavoidable fate over which we have no control. This can present a real challenge for health care providers, especially if the patient believes that there is nothing that he or she can do to change the situation.

To encourage a patient to make efforts to overcome an illness, one might say…

• ×          “God may be testing your faith and want to see you make efforts to improve”
• ×          “There may be other missions in life that God has planned for you and overcoming this obstacle might be important in achieving the others”
• ×          “God or the saints may be impressed with your perseverance and unwillingness to give up."